Intended for healthcare professionals


The NHS through American eyes

BMJ 2000; 321 doi: (Published 23 December 2000) Cite this as: BMJ 2000;321:1545

It has an enviable goal and constancy of purpose: build on it

  1. Sheila Leatherman, senior associate (sheila_t_leatherman{at},
  2. Donald M Berwick, chief executive (dberwick{at}
  1. Judge Institute of Management, Cambridge University, Cambridge CB2 1AG
  2. Institute for Healthcare Improvement, 375 Longwood Avenue, Boston, MA 02215, USA

Criticism from without, demoralisation within, and ubiquitous scepticism besiege the National Health Service. The NHS Plan, released in the summer,1 is the latest in a series of blueprints intended to redefine the resources, programmes, and operating principles of the NHS, but it too has met its share of cynics. We are two Americans, privileged to have an inside view of the NHS and its proposed reforms, and we share an optimism about the NHS that is hard to find in the UK nowadays.

Not that we don't see the trouble. The performance problems of the NHS are no secret. Some reflect random episodes of malfeasance, such as the murderous Harold Shipman, but more chronic problems afflict the NHS as a whole and, in aggregate, cause far more suffering and waste. They include long waiting lists, postal code variation in practice, and poor outcomes in cancer care, and they caused the UK to lag ninth out of 15 European Union countries in the World Health Organization's recent ranking of health systems.2 Yet, while many in the UK wring their hands over the problems, we continue to believe that the NHS has fundamentally “got it right.”

Firstly, the NHS has a mission: universal care. It is unifying, bold, just, and as correct today as it was in 1948. The basic ethos recognising health care as a public good was visionary when the NHS started, and it continues to resonate in the contemporary world. Universal coverage does not automatically imply nationalised health care; indeed, most western nations committed to universality have not created a behemoth like the NHS. Are there sufficient benefits in the monolithic NHS to balance some of the costs?

We think nationalised health care was a wise choice in 1948 and that it remains so now. Finding the right balance between centralisation and decentralisation is a never ending struggle for any large organisation, public or private. But, because it has an NHS, the UK has a continual opportunity to align policy, capital resources, programme priorities, and operating budgets on a scale available to few other nations. The UK can decide, as an entire nation, to improve its cancer care outcomes, reduce waiting times for care, and better integrate community health resources and hospital care. Indeed, the recent NHS Plan proposes exactly those improvements and backs up the strategy with specific plans, accountable management structures, and major infusions of money. Promising new infrastructure has been implemented: the National Institute for Clinical Excellence to identify the best scientific knowledge to guide clinical care; the Commission for Health Improvement to monitor quality; and a new Modernisation Agency to spread best practice.

Where else in the Western democracies can one find such open, comprehensive, and aligned efforts to shape better health care on a national scale? In contrast, the efforts to improve health care in the United States remain mired in debates over pricing and reimbursement, secrecy among competing organisations, timidity about admitting that quality problems exist, and continuing tolerance of the national shame of over 40 million uninsured Americans. The WHO ranked the UK 18th out of 191 countries in the performance of its healthcare system; but it ranked the United States (which spends 40% more per head on health care than Britain) 37th, partly because the American health care system is so inequitable.2

We have no doubt that the NHS must improve on its current performance. The status quo is not sustainable; nor does this summer's NHS Plan provide the ultimate blueprint for success. The problems are too challenging and the environment is too dynamic for “instant pudding” solutions.

However, the answer lies in trying. The increase of 30% in funding the NHS over the next five years should provide the needed capital to modernise undercapitalised facilities and fund investment in information systems. Adding more capacity is critical in a system widely recognised as understaffed. But we caution NHS planners not to overshoot. Oversupply has been shown to correlate with higher rates of hospitalisation and procedures in health care that are clinically unexplained.3

Specific performance improvements should be targeted and pursued system wide. We believe that national aims—such as improving cancer outcomes, improving care for heart disease, and improving mental health interventions in crisis—are helpful in establishing focus and coordinating national resources. We suggest developing centralised “big picture” aims, while nurturing innovative and pluralistic local initiatives to realise gains “on the ground.” The NHS wastes its most promising resource—the talent of its people—when it discourages clinicians and managers from initiatives that would improve care locally.

Emphasise learning over regulation as the linchpin strategy for improving care. The NHS Plan calls for increased levels of measurement and accountability throughout the NHS. These are important. But more important for the long haul is the NHS's capacity to learn from its own best practices and innovations and spread those good ideas throughout the nation. That requires the system to develop and maintain world class educational and training opportunities for its staff and clinicians.

Depoliticise the NHS as much as possible. A side effect of nationalised health care is that it becomes interwoven with national politics. This can garner resources and propel change, but it can also confound constancy of purpose. Reform fatigue and scepticism are real dangers in the NHS, particularly when too many people start to believe that the political agenda is driving the health agenda. Britain's political and health care leaders need to maintain the long term view and the discipline to assure that NHS modernisation will be shaped by the simple and abiding values of equity, efficiency, and effectiveness.

The NHS was a wise choice when it began: it remains so, as a truly national system of care, second to none in its ambition and capacity to serve the health of the public As the leaders of the NHS struggle to create a healthy future, they bear the burden of leadership, both at home and in the global health community.


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